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Comment by callumprentice | Hacker News Reader

The other side of removing transportation as a barrier to care is have the doctors come to you. We've started using Heal (http://heal.com) recently when the whole family was sick with the flu and it was great. Doctor and assistant come to your home within a 2 hour window. Cost is same copay you incur at a doctor's office. We used it several times and doctors were great. Seems like a no-brainer to not force sick folk to travel and spread germs. Only downside really was that you don't usually see the same doctor twice although I believe you can request by name.

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That sounds like a good plan if you have good insurance, but it doesn't sound like a sustainable way to improve health care service to a wider population. Doctors are a scarce resource, and having the doctor drive around to each patient's house is not a very good use of their time.

At my Doctor's office, the doctors are scheduled for 15 minute appointments. at an optimistic assumption of 15 minutes travel time to and from each appointment, a model where the doctor visits each patient requires 3x as many doctors for the same level of care.

Cost could be minimized if the particular doctor does not have to pay for a facility. I can't even begin to imagine what the cost per sq/ft of a generic doctor's office is, given all the regulation and equipment requirements. Having them mobile may remove a significant cost (though probably won't come close to the added opportunity-cost you mentioned).

I can’t see how there would be any cost savings except if you dump equipment that would otherwise be available; making the entire contents of a clinic mobile is surely more costly and complicated than paying rent.

Test kits are mobile, vaccines and bloodwork are mobile, basic diagnostic equipment is mobile. Most people do not need the vast majority of things a clinic contains; nothing you couldn't solve with a small refrigerable unit in a vehicle.

That being said, the downsides of travel time are so negative it's hard to see how they could be overcome.

> I can’t see how there would be any cost savings except if you dump equipment that would otherwise be available

Compared to an urgent care facility, they pretty clearly have to be doing that.

My point wasn't just about cost, but rather care. People need doctors, and "there isn't enough doctors" seems to be a common problem in health care. The cost could also be mitigated by simply charging more, but having doctors spend their time driving instead of treating patients means that the number of doctors needed for the same quality of care goes way up, and in many cases doctors are not a resource that you can simply get more of because you need more.

For every doctor's appointment serviced by Heal, ~3 appointments are taken away from a community clinic somewhere.

>For every doctor's appointment serviced by Heal, ~3 appointments are taken away from a community clinic somewhere.

It sounds to me like you may be making unjustified assumptions to get to that conclusion. Citation?

I outlined my reasoning in my post above, unless heal is creating new doctors they are hiring away doctors from more efficient types of care.

Your reasoning is based on assumptions that there is no evidence for. Not all doctors are employed in providing care, you don’t know what Heal doctors are doing between seeing patients, you don’t know how Heal sources or compensates doctors, medical efficiency is not measured in patient-minutes, you don’t know how many patients a Heal doctor sees vs a clinic doctor, you don’t know the bottlenecks of community clinics, etc. etc.

> Your reasoning is based on assumptions that there is no evidence for.

I have no horse in this race, but I found it interesting that the above was followed by four “you don’t know…” statements.

You’re making assumptions as well. The person to whom you are responding may know a great deal more than they have revealed.

https://en.m.wikipedia.org/wiki/Tu_quoque

Do I contradict myself? Very well then I contradict myself, (I am large, I contain multitudes.)

You’re actually right about this. My primary care doctor tried one of these “visit people instead” services and absolutely hated it. Her days are usually 100% full at her office but driving around SF all day cut her throughput down to something like 30%.

Maybe the economics work somehow for others, but they didn’t for her (car + gas + parking + large drop in number of patients seen).

> doctor does not have to pay for a facility

> given all the regulation and equipment requirements.

Um, so how does not having a facility, which is probably required to give care, all of the sudden eliminate all of the equipment and regulatory requirements? I mean, don't you think the equipment and the regulation is probably there for a reason..?

Well, if you build a clinic it needs to be wheelchair accessible, and have access to parking for all the patients that might be present at one time, for example. If you visit patients then they either live somewhere accessible or not and you just need to get one car to their place.

> Um, so how does not having a facility, which is probably required to give care

It's required for certain levels of care, but not every encounter requires those.

Same way a taco truck is cheaper to operate than a sit down restaurant. You still have to follow the local health codes but your fixed costs would be less.

Doing this with Facetime and some other tools (telehealth) might be the best of both worlds.

How would "open your mouth and say aaaahhh" work over Facetime? Some things need a hands-on approach.

Yes, but only some things. My brother and best man are doctors, and we have a home doctor service and a GP. The first two provide ample support for most instances.

> That sounds like a good plan if you have good insurance, but it doesn't sound like a sustainable way to improve health care service to a wider population

A home visit of a physician is hardly a new concept.

If I'm not mistaken, it's a norm in France, and I know that it functioned that way in the USSR (not sure about the modern Russia). The doctors were indeed complaining about the number of visits but somehow it functioned: while booking a specialist or finding quality equipment was an issue, there was rarely an issue to book a visit of a family doctor within a couple of days' notice, at least in a big city.

> (not sure about the modern Russia)

Highly dependent on the hospital and provider you have. Modern Russian does have a general government health care for most things, but you can also get private insurance. For the general care, you usually end up going to a local community clinic. For paid insurance, typically you can get a home visit within a few hours from a doctor who does the basics and writes you a doctors note for sick leave. (My experience has been that the sick leave is pretty generous; last time I had the flu I was given a week's rest, then for my follow up the doctor told me to take another 3 days)

It's not perfect for other things, but compared to the health care situation I had when still living in the US, this facet is far better. (at my last job in the US, both Insurance and my Work Place refused to approve sick leave for a summary from my in-network GP that suggested that a treatment required several days of recovery after some radiation therapy. They said I'd have to go to another clinic to have the situation reviewed; the second clinic decided I was fit to work so my choices were either burn vacation days or sign a form to accept time off without pay during recovery.)

As a French, I can tell you we go to the doctor office / hospital 99% of the time, it’s very rare for the doctor to come to you, except for nurses.

(Filthy thoughts aside) Why the differentiation? What's the purpose of the nurses visiting?

> At my Doctor's office, the doctors are scheduled for 15 minute appointments. at an optimistic assumption of 15 minutes travel time to and from each appointment, a model where the doctor visits each patient requires 3x as many doctors for the same level of care.

It's not "either/or", there is no reason not to have both systems running in parallel. I would have no issue paying a doctor more for him to come visit us at home, to ensure it makes it as profitable for them to do that.

We have this large scale in France, as “sos medecin”.

The key points are the “I need help” focus right in the name, and a triage process done by phone.

They’ll deal with sny unforseen event that needs medical attention. It can be a severe pain in the back in the middle of the night or high fever for a kid, anything that is not a regular check-up or renewing a prescription.

Then there’s pre-filtering of the calls to decide if it’s worth it to send someone, or if the patient better come to the office, or straight up call official emergency services.

Price is higher than an usual consultation but not that much, and interestingly it’s also higher than ER in a public hospital, so you have incentives to choose the right service for you.

We end up using it a lot because usually we detect our kid is sick after picking up from school or during week-ends, when normal offices are already closed and there’s no hope to get an appointment.

Or, maybe we shouldn't just roll over and accept artificial scarcities driven by archaic, guild-like gatekeeping and capitalism.

https://www.motherjones.com/kevin-drum/2013/11/its-doctors-w...

> So the number and composition of residencies is controlled by doctors, even as they’re subsidized by $13 billion in taxpayer money every year. And doctor pay, which almost everywhere is based on Medicare rates, is controlled by doctors. It’s doctors who are directly responsible for both their own high pay and their own low numbers.

https://washingtonmonthly.com/magazine/julyaugust-2013/first...

> The U.S. spends $13 billion a year subsidizing graduate medical education. Yet almost all of this money winds up producing the wrong kinds of doctors in the wrong places, with America’s most elite teaching hospitals being the worst offenders.

I only don't see how it's a shortcoming of capitalism. I'd say it's the lack of capitalism, with its free market competition. Artificially limited supply is usually a result some state-enforced regulation.

Its kinda sad to see this sort of service. Home visits are a key part of healthcare, but it doesnt scale and is potentially harmful. Especially when you realise that most people dont really need to see a doctor.

Flu is a great example (not judging you, I have no idea how bad it was!) where most people could self care.

Much better is phone doctors & good websites; the NHS have invested heavily in this. You can self-care for many minor things based on online guides, and are then directed to a phone GP for triaging if you need further help.

(example online guide; https://www.nhs.uk/conditions/flu/ what I like about it is that it gives you clear exoectations about self care and when you should feel better, plus clear (and varied) escalation paths for worsened symptoms)

Most healthcare startups in the US are treating symptoms of the problem (poorly) instead of the underlying issue (a fundamental failure of the healthcare system).

I was in bed for 3 weeks with real flu - not a runny nose or even a nasty cold. Plus, we just moved to a new neighborhood and finding a (good) primary care doctor you can visit is all but impossible - they're all full and not taking any new patients.

The Heal service was an immense win for our family's situation.

The NHS does that because there’s already a massive problem with too high demand and too little supply. Making health care “free” distorts incentives — so they have to come up with clever ways to implement barriers to care: waiting lists, attempts at convincing people of self care, etc. Does that NHS website provide a prescription to Tamiflu as well? Does the website know our medical history?

If people paid directly for visits, there’s a built in incentive to reserve doctor visits for when they are actually necessary, rather than the British system of “free” (provided you can jump through enough hoops to actually earn an appointment.)

Using the NHS as a model of “good” health care is laughable. What’s “good” about the NHS is that it’s “free.” It isn’t actually good when it comes to access to care or advanced treatments. Compare cancer death rates of the UK vs the US, for example. The French system where you actually have to pay some money for appointments is far better — you don’t have to wait weeks to visit a GP: I can get pediatrician appointments generally same day. That is literally impossible in the UK. I also am not getting referred to a “website” to solve my kids’ illnesses — I am not an idiot, I know how to google. I am not going to waste my time going to a doctor unless I actually feel that the doctor can provide some value.

Want to better allocate a scarce resource? Make people pay a price that reflects the available supply instead of making it “free” but with convoluted access models.

> Does that NHS website provide a prescription to Tamiflu as well?

Well, no. And this is why: https://www.nhs.uk/news/medication/effectiveness-of-tamiflu-...

What I love here is that there is clear, documented information about the choices on offer - and background into why the NHS recommends paracetamol/ibuprofen on its website.

> Compare cancer death rates of the UK vs the US, for example

Okay; looks like they are nearly identical for US, UK, France (105, 107, 109 per 100,000).

> That is literally impossible in the UK. I also am not getting referred to a “website” to solve my kids’ illnesses

This is the thing - emotively if your kid is ill it feels like they need a doctor. But likely they just need rest and over-the-counter medications (I've always found the pharmacist to be a good port of call for the right advice here).

If you do need a GP for your kid I have never had any problems getting one; day or night.

> I am not going to waste my time going to a doctor unless I actually feel that the doctor can provide some value.

In which case, great, but then I think you're not the target for these sorts of initiatives as you are using healthcare appropriately.

> Especially when you realise that most people dont really need to see a doctor.

With regards to the US, the issue isn't the medical need to see a doctor, it's the bureaucratic need to see one, as you can't get approved for extended sick leave without it.

Such visits (and per this document [1, pg 7-8], many ER visits) are for purely bureaucratic reasons, such as no insurance or no other providers available. I interpret this as largely a workflow issue with regards to the availability of the simple care. A separate style clinic or service dedicated and allowed by Employers/Insurance which deals in low-priority cases for the purpose of documentation (e.g., flu clinics) would solve a lot of these issues, but, as I found out with my previous employer and insurance, flu clinics are "not real doctors", and as such cannot be submitted for sick leave claims.

I think we'd see the numbers for inappropriate/unnecessary visits drop rapidly if Employers/Insurance accepted such documentation more easily/readily.

[1] - https://www.cdc.gov/nchs/data/nhsr/nhsr090.pdf

Very interesting, and important, point - thank you!

It goes to show that healthcare is intrinsically linked into so many parts of our daily lives in weird ways.

There's definitely a need for it. I'm working for a startup, called Carol Health[0], that's trying to do a similar thing but with nurses instead of doctors.

There's a huge need for in-home care, especially in the aging population. For able bodied humans, going to the doctor's office is a pain but not a particular challenge. For aging, disabled, or mobility-limited individuals, it can be nearly impossible for them to get to a doctors office. Not to mention, an office is full of nasty things that can harm immuno-challenged individuals more than the office visit can benefit.

Telemedicine is a really good start, but there are huge limitations without being able to actually interact with a patient. As more of these types of services popup, it's going to be incredibly beneficial for aging and homebound or almost homebound individuals.

It really exciting to see a whole gamut of services, like Shipt and ClickList, popup. Hopefully in 10 years, aging in place will be more common until the point that individuals actually require frequent assistance or medical attention.

[0] https://www.carolhealth.com

How do you deal with patients keeping the doctor there for an hour? Drives taking an hour in between? It's nice and I'd love it, but I can't see how it's feasible against an office where they can see 6 patients an hour. Great pricing however. Is it really $99 total? That's cheaper than driving and a copay.

In my experiences, they're in and out pretty quickly. I didn't feel rushed but certainly not the mellow chit-chat I've experienced in the past when I visit my regular doctor where I used to live.

My cost is $20 per visit for the copay - I guess they bill the insurance company in the same way as if you'd gone into the practice.

> Is it really $99 total?

$99 is the cost with no insurance; with insurance they bill and you pay your normal copay. $99 is probably less than their average reimbursement.

> That's cheaper than driving and a copay.

If you have really high cost of driving, have poor insurance, or are comparing it to average urgent care copays instead of primary/specialist office visits (IIRC, copays for primary average around $25 and specialist around $40; $60-75 seems improbably high transport cost for most people to drive to a doctor, even with non-free parking), sure. But unless appointment availability is really high, it's going to be higher latency, on average, than urgent care, and in any case it seems necessarily to be less well equipped than most urgent care facilities (meaning you are more likely to need to go somewhere else and be seen after your visit when using it as an urgent care.)

Note that $25 is nowhere hear the average for Americans' copay for primary healthcare visit. You've just got really excellent insurance and are assuming everyone else does as well. We've got average insurance in our state, and copay is around $60.

> Note that $25 is nowhere hear the average for Americans' copay for primary healthcare visit.

$24 primary, $37 specialist, though that was published last year so it may have crept up a bit (it's been trending slowly upward.) [0]

> You've just got really excellent insurance

$25 is more than my primary care copay. I know I have excellent insurance; I also don't assume everyone else's is like mine. OTOH, you apparently have really crappy insurance and are assuming everyone else does.

[0] http://time.com/money/4044394/average-health-deductible-prem...

> Once workers have surpassed their deductibles, they pay an average $24 copay for a primary care office visit, $37 for a specialty care office visit,

Note that, as stated in the article you linked, the percentage of plans with deductibles has gone up significantly (67%). So your average is really a veiled figure - many people won't come close to spending as much as their deductible on healthcare in a year to ever actually pay those prices.

We are nearing crisis mode regarding long term home health for the elderly here in US. Cost per visit for even non-nursing, personal care workers can easily exceed $100. Medicare coverage eligibility is subject to political risk. It's a significant tax on working families. And with 30-40M families requiring such workers. It's trivial to see how there may never be sufficient labor market supply.

But a subscription service model for those that can afford the highest quality home care for the elderly. Represents a phenomenal startup growth opportunity.

I have trouble understanding how doctors can make money with Heal? For me it is great, $99 and I have nice doctor show up when I don't feel well and diagnose and prescribe treatment. I don't understand how they can make money with this.

Doctor isn't paying overhead for an office, plus they get paid more than the co-pay by your insurance.

An average gp makes about 170k with tax benefits etc its probably closer to 200k. Assuming they get 3weeks of vacations that 102 dollars/hour. I don't see how 99 dollars per visit makes economic sense.

How many hours a week do they work? How many of those are overhead hours that Heal takes care of for them? How many of them are average? What other costs of running a clinic are there?

I’m wondering if a lot of them aren’t working part time while doing something else? Like I can see it being really appealing for a doctor with young kids at home that don’t want to work long hours.

We've had home-visit GPs in Australia for a few years now. There's multiple to choose from, and they're all covered by Medicare (so it's "free" to use).

It's super handy for us, having 2 people in our family with illnesses that require regular doctor visits (once or twice a month on average). If it's night time and we need the GP, we don't have to worry about waking up the baby, loading up the kids and nappy bags and everything we need into the car, etc.

We only go and visit our actual family GP if we need prescriptions renewed, or we want to talk to him about a bigger issue or general questions. Eg stuff that isn't urgent, so we don't waste the home-visit GP's time. Then again, the home-visit GPs have told us multiple times that they're happy to come out no matter how small the issue, and they prioritise/triage calls so you're never keeping a more urgent case waiting.

This is a horrible and expensive healthcare system for any society.

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